Skip to contents

We Spoke to an Expert About Medicaid Unwinding in Georgia. Here’s What We Learned.

Local economist Ife Finch Floyd says the state has underfunded and underinvested in organizations needed to help residents maintain coverage.

In Georgia, and across the country, states find themselves understaffed at departments where Medicaid eligibility workers are employed. (Joey Ivansco/Associated Press)

The countdown is officially underway. In just over two weeks, the state will start the process of reviewing and reevaluating eligibility for the 2.7 million people in Georgia on Medicaid and PeachCare for Kids. Under the federal continuous coverage mandate, which has been in place since the start of the COVID-19 pandemic, states were required to keep people on Medicaid without reevaluation. The move was meant to help patients keep coverage in a time when job loss was prevalent and more health care was needed as COVID-19 spread across the country. 

The unwinding of coverage, which is part of the overall end to the federal Public Health Emergency for the pandemic, has been in place since March 2020. The approaching deadline is one that public health analysts have been worried about for months. 

In Georgia, and across the country, states find themselves understaffed at departments where Medicaid eligibility workers are employed. 

“When there’s not enough staff to address the needs, to address the questions, to make sure that the information is getting to clients, this is where you begin to have those procedural denials that are really unnecessary and unfortunate,” said Ife Finch Floyd, the director of economic justice at the Georgia Budget and Policy Institute, a nonprofit organization that researches and analyzes the state’s budget to promote equity in areas that include education and health care.

Capital B Atlanta spoke to Floyd about the potential loss of coverage for Black and brown families, how Medicaid expansion could help, and the staffing challenges facing government agencies working to help residents.

Capital B Atlanta: So how did we get here? Why did the federal government give folks a break, and why are they changing that?

Ife Finch Floyd: At the beginning of the pandemic, the federal government wanted to make sure that more people had access to health coverage, particularly during a public health emergency. If people got COVID, they wanted to make sure people had health insurance so they can get the kind of care that they need. … Say a pregnant mom got on pregnancy Medicaid in Georgia, that [typically] only lasts a few months, but under continuous coverage, she could stay on and it not be reconsidered.

It allowed people to maintain their coverage and not have their eligibility reconsidered, and it’s been going on for almost three years now. … I’ve seen estimates between 2.6 million, 2.7 million people in Georgia who are on Medicaid today.

And under this continuous coverage, what kinds of things have changed for the better and for the worse?

More people were covered under this kind of pandemic-era policy than before. That means [if] they got COVID … and they had to check themselves into a hospital, that means they didn’t come home with a huge medical bill that they couldn’t then cover.

It means that people could go to the doctor if they needed to. So we see this as more people getting covered and basically more people being able to access the health care that they need in order to remain healthy and … go about their lives. 

It is our position that Georgia should expand Medicaid to make sure more people have this benefit and that they can maintain healthy and productive lives, because that’s so critical to making sure that you can go to work, that kids are present in school and they’re healthy. All of those things really rely on families and kids and parents and caregivers and workers being healthy. Making sure that people being covered under this continuous bridge, we saw that as a good thing, and that there were benefits to that, and that they didn’t come home with those major health care costs.

I was going to ask about Medicaid expansion, actually. I know the Democrats, like they do every year, put forth a Medicaid expansion bill. Gov. Brian Kemp says expansion would cause the state to lose money. Have you all seen any evidence of improved health or financial outcomes with discontinuous coverage?

Speaking of postpartum, we know that that is helping pregnant people take care of the issues that come up after delivering a baby. It doesn’t just end after you have a baby. There’s mental health issues that could arise, there’s other physical issues that arise, and some of that maternal mortality, maternal morbidity, those problems — particularly for Black women and Black birthing people — that can happen in those 12 months. So we know that having health coverage is critical to making sure that they’re remaining healthy, they are able to be the caregivers that their babies need. 

In light of the looming April 1 deadline, can you explain what’s going on with Medicaid eligibility workers in the Georgia Division of Family and Children Services?

I want to take a step back for a second, and it’s just to say that the state really has not invested in its workforce for a long time. This is years in the making. We have seen recent increases across the board for qualified state workers’ pay. We saw that with Governor Kemp’s $5,000 pay increase last year, and that certainly it was a great improvement. When you look back 10 years even, we just see steady declines in the state workforce, and particularly in human services. So if we’re looking at the Department of Human Services or DFCS … which is under the Department of Human Services, those numbers have steadily declined. 

This is a part of a larger trend, the state just not investing and continuously updating or boosting pay for these workers and boosting support for these workers. So you have continuous retention issues, high turnovers. We’ve heard this around child welfare workers especially, but it’s also happening on … the public benefit eligibility side. That’s in the Office of Family Independence within DFCS. We’ve continued to hear about large caseloads for these eligibility workers — eligibility workers experiencing burnout, stress, declining mental health because they feel like they can’t keep up with their caseload and the pay is not keeping up with how much they’re working. I’ve heard from people who used to work for the agency say they used to not be able to really even hire anybody, even before this last pay bump of $5,000.

We know that $5,000 was meaningful, but I question if it’s really enough, particularly with Medicaid unwinding right around the corner. 

We have an issue with underpaid and overworked staff at DFCS, and that’s going to create an unstable environment, and we haven’t even gotten to Medicaid unwinding yet. … I’ve heard that the agency is quickly trying to hire those folks. And then, of course, the governor also proposed a $2,000 pay increase. Those are positive steps, and GBPI is supportive of those steps. Again, I am not confident that that’s enough to really address the turnover.

Since the COVID-19 pandemic, states were required to keep people on Medicaid. (Marko Geber/Getty Images)

Can you explain what sorts of things DFCS workers have to do? How does that cause someone who is at risk of losing Medicaid to fall through the cracks?

So that’s a great question. So they have to look at all the information associated with eligibility, and a lot of it is around income. 

The state is investing in technology and things like that to help make sure that some of the more manual and kind of repetitive tasks of reviewing that eligibility is taken off the workers. So there is some investment there, but that’s not going to solve every situation, and some situations are very complex. And there could be a challenge of just reaching out and getting in contact with [someone]. The agency has requested multiple times for folks to update their contact information in Gateway. So Gateway is an online eligibility system, and they want to use that system more and more because they know that staffing levels are lower than they really need to be to have more in-person contact. Some people just might not have gotten that message. They need to update that information.

They might not even know this whole unwinding is going on. And then what could happen if the caseworker can’t verify all of this information, this eligibility information, then that person could be cut off, not because they’re ineligible, but for these procedural reasons. … 

When you can’t do that, right, because you have fewer and fewer staff, it could increase the likelihood for these procedural denials of coverage, again, not because of that child or that individual is ineligible for coverage, but just because of the issues of not being able to reach out.

That makes sense. 

A lot of folks, they like to just be able to call a caseworker or go into the office to say, “Hey, what’s going on with my coverage,” or, “What’s going on with my Medicaid case? Can I figure this out,” or, “What’s going on with my child’s Medicaid case? Can I figure that out?” Well, because we’ve had years of decline of frontline workers, and I think even with this hiring spree that we have, we still won’t be at a level where they can fully reopen offices.

These are the challenges that we’re talking about. When there’s not enough staff to address the needs, to address the questions, to make sure that the information is getting to clients, this is where you begin to have those procedural denials that are really unnecessary and unfortunate, and it could mean an unnecessary loss of coverage for a lot of kids, and a lot of those kids are likely to be Black and brown kids.

How would people know they’re at-risk for losing Medicaid, but also what difficulties can they anticipate when trying to stay on? And it sounds like some of that has to do with the underfunding of DFCS and the underemployment at DFCS.

I think DFCS has often struggled with effectively communicating certain things. Now, for Medicaid unwinding, they did hire a PR firm to get the word out. Again, that is a positive step. They’ve been doing TV slots and radio slots and putting things on social media, so we really are investing in a campaign to make people aware. I think that is a good step. It is not enough. They’re just not going to catch everybody. 

DFCS can’t do it all. Right? It’s a lot. It’s 2.6 million people who have to be covered, but that’s where community organizations really could be a big help. And a lot of community organizations already work with DFCS to help get people in the community signed up. For example, the Latin American Association worked a lot with the Spanish-speaking population in north DeKalb and Gwinnett counties. The Atlanta Community Food Bank also does a lot of work in the Atlanta region, and there’s other community organizations across the state that do this work. I think if the state were to have invested in those community groups and those trusted messengers, that could have been an additional way to go even deeper in helping families understand what they need to do to maintain coverage.

What I’m hearing is that because of several factors, that’s easier said than done.

Poverty makes people’s lives very complicated. They have irregular work schedules, like you were talking about, not having a lot of flexibility. They don’t have all the resources. If they have to do things on their phone because that’s their only thing that’s connected to the internet, but what if they don’t have Verizon and they’re paying for limited data? They can’t fill all this stuff out on their phones. But that’s the unfortunate thing. We can’t say we can’t ignore technology and we should utilize technology and the state should utilize technology to expand access. I think when you’re talking about, again, people who are receiving Medicaid or the kids who are receiving Medicaid, I think some of it has to be a lot more thoughtful about that approach. 

The technology has to be very intuitive, very easy to use. There have been those who have high literacy, technology literacy, and still struggle to utilize some of the Gateway systems. It doesn’t always reflect the reality of people’s lives, and sometimes people just want to talk to someone because that’s what feels comfortable. Another piece I’ll share that the state is doing —  again, I have concerns with this —  they are going to put these Gateway kiosks in, I think, more than 400 public libraries across the state, or at least 400 kiosks across the state, but they’re going to be in libraries. And they did this to address the kind of the concern about poor internet access in certain areas, particularly rural areas, for example.

What I think is going to happen is that, OK, people will hear about the kiosks, they’ll go to the kiosk because they can’t go to the office. They’ll try to sign in and then they’ll have a question, and who are they going to ask? They’re going to ask the librarian, who probably doesn’t know anything about Gateway and certainly doesn’t know anything about Medicaid. So I think that’s an additional burden that could be put on librarians. And even if they say, “I can’t help you,” then has that person been adequately served just because you provided them a kiosk?

I think there’s serious questions there if you haven’t solved for connecting people to caseworkers.

This story has been updated.